Discharge Planning, Transfer Summaries, and Transitions of Care

Runs an effective discharge planning process from the start of care: the patient’s goals and preferences guide planning; patients transferring to another home health agency or discharged to a skilled nursing facility, inpatient rehabilitation facility or long-term care hospital are helped to choose a provider using quality and resource use data; necessary medical information goes to the receiving provider; and the discharge summary is sent within 5 business days of discharge and the transfer summary within 2 business days of a planned transfer or of learning of an unplanned one.